Reposted from CAPPA Connection
by Laurel Wilson, IBCLC, CLE, CCCE, CLD
CAPPA Executive Director of Lactation
All human babies have the right to breastmilk exclusivity. This can be accomplished in a variety of ways - exclusive feeding at the mother’s breast, exclusive mother’s expressed breastmilk delivered to the baby via a feeding device, or pasteurized donor human milk delivered via a feeding device.(1) However, there has been a new form of delivering breastmilk to newborns, older children, and adults that is getting more attention, even in publications such as TIME magazine.(2) This is the concept of milk sharing. Milk sharing is when women provide breastmilk directly to another family in need, without going through the donor milk bank process.
This type of milk delivery system has been increasing since the rise of social media, making it easier for families and the lactating mother to connect virtually. Examples of organized milkshare sites include the following:
• Eats on Feets http://www.eatsonfeets.org/
• Human Milk for Human Babies http://www.hm4hb.net/
• Milkshare http://milkshare.birthingforlife.com/
• World Milk Sharing Week, Last week in September http://www.facebook.com/WMWeek
Human milk banking in the United States is managed through eleven human milk banks that are part of the Human Milk Banking Association of North America.(3) The banks are located in California, Colorado, Indiana, Iowa, Michigan, Missouri, Massachusetts, North Carolina, Ohio, and Texas. The donors are thoroughly screened through a detailed questionnaire, blood test, and finally testing the milk. Once donors are approved, they donate their milk which is then mixed with the milk of several other mothers’ milk, pasteurized, and tested again. It is then sealed and prepped for delivery. For a family to gain access to donor human milk, the patient must get a prescription from a doctor. Milk banks require a prescription to ensure that the neediest patients have access to the donor milk, as donor milk is in limited supply and they must distribute the limited resources.(4) Babies who are sick or premature have the first priority to obtaining donor human milk. These babies need milk that has been thoroughly screened, tested, and pasteurized to ensure minimal risk. The donor milk costs between $5-$8 per ounce. If the individual has a demonstrated medical need for the breastmilk, such as a baby in the NICU, often health insurance will pay for the donor milk. Due to this limited availability and screening, donor milk is not available to many families who desire breastmilk exclusivity for their babies and cannot personally provide that resource, mainly due to medical or physiological issues.
There are very few times that an infant would be better off to have artificial milk. As per the World Health organization, these rare instances include the following:(5)
• Infants with classic galactosemia: a special galactose-free formula is needed.
• Infants with maple syrup urine disease: a special formula free of leucine, isoleucine, and valine is needed.
• Infants with phenylketonuria: a special phenylalanine-free formula is needed (some breastfeeding is possible, under careful monitoring).
In all other situations, human milk is considered the best food for human babies. Perinatal professionals should be well-versed in the risks associated with artificial milk feeding. Providing education on these risks is an important part of informed consent/refusal for families needing to consider supplementation for their child.
While peer to peer milk sharing is gaining popularity among families, finding policy and recommended practices can be difficult. The Academy of Breastfeeding Medicine only references mothers own expressed milk, donor human milk, or hydrolyzed or standard infant formulas for breastmilk feeding in regards to supplemental feeds. The World Health Organization, states in its Global Strategy for Infant and Young Child Feeding, “for those few health situations where infants cannot, or should not, be breastfed, the choice of the best alternative – expressed breast milk from an infant’s own mother, breast milk from a healthy wet-nurse or a human-milk bank, or a breastmilk substitute…depends on individual circumstance.”(5) Most milk share organizations recommend the practice of using The Four Pillars of Safe Milk Sharing.(6) These are informed choice, donor screening, safe handling, and home pasteurization.
What are the concerns perinatal professionals have with peer to peer milk sharing?
There is serious risk of exposure to pathogens, bacteria, viruses, drugs, and chemicals.
However, new research suggests that most of the pathogens of concern can be killed by flash-heating at home.(8) Holder pasteurization and flash-heating are both processes that can be accomplished when milk sharing to provide protection against most illnesses.
What do families need to know?
Families considering using peer to peer milk sharing should follow the “Four Pillars of Safe Milk Sharing” (6)
• Informed Choice
• Donor Screening
• Safe Handling
• Home Pasteurization
The family receiving peer to peer milk should should fully educate themselves on the benefits of using human milk as a supplement, as well as the potential risks. These include: (6)
• Pathogenic transmission to a baby, causing illness or even death
• Potential sabotage or harassment by donor
Families should strongly consider screening potential donors:
• Ask to see pregnancy blood tests or pay for blood tests to be done. Screening should include HIV I & II, HTLV, HBV, HCV, Syphilis, and Rubella. CMV, TB, and WNV.
• Use a questionnaire for the donor that request information about lifestyle and medication use.
• Make sure milk is handled and transferred in an optimal hygienic environment.
• Flash-heat or Holder pasteurization methods should be used on the milk before the baby receives it.
The family donating milk also has a few considerations. They have the option to donate to an organizational member of the Human Milk Banking Association of America or directly to a peer. Families can facilitate their donation by either contacting HMBANA directly, in the case of milk bank donation, or by utilizing the peer milk sharing organizations online. All donors should consider the benefits as well as potential risks of donation. The risks vary, but can include issues such as litigation in the event of a bad outcome and potential, though unlikely, harassment by recipient. Donors should expect to fill out a screening form and provide a blood sample at the expense of the person receiving milk. Donors also have a responsibility to follow proper storage and transfer guidelines for breastmilk. http://milksharing.blogspot.com/2010/12/freezing-breastmilk.html
The Four Pillars article suggests that families first self-screen. Self exclusion should include the following: (as per Walker and Armstrong) (6)
• “Health
• Poor general health
• Suffering from severe psychiatric disorder(s)
• Confirmed positive for HIV I, HIV II, HTLV I, or HTLV II
• At-risk for HIV (including sexual partner)
• Current outbreak of herpes or syphilis lesion
• Current open sores, blisters, and/or bleeding cracks on the skin
• Undergoing chemotherapy or radiation treatment
• Receiving radiation treatment or thyroid scan with radioactive iodine
• On medication contraindicated for breastfeeding
• In the fever stage of chicken pox or shingles
• Lifestyle
• Currently abusing drugs, alcohol, or OTC medicines
• When donating to a premature or critically ill baby: drinking, smoking, using certain herbal supplements, or taking megavitamins
• Social
• Feeling coerced
• At risk due to religious/social conventions”
After doing the research, CAPPA strongly feels that the perinatal professionals role at this time regarding peer to peer milk sharing involves acting as an educator, not a facilitator. While it is the decision of every perinatal professional to make their own judgments regarding milk sharing, it is important that all professionals carefully consider all aspects of milk sharing and provide balanced and evidence based information to all clients when asked.
CAPPA Statement on Milk Sharing
While CAPPA professionals should educate families on the benefits of using human milk versus artificial milk, they should also educate on the potential risks that are involved with informal, non-regulated milk sharing to ensure that families utilizing this form of breastmilk access can mitigate the risk as much as possible. CAPPA discourages its professionals from acting as barters for milk sharing, and strongly encourages all professionals to consider the implications of acting as a facilitator for accessing shared milk. While it is important to educate families on all of the benefits of human milk exclusivity, CAPPA professionals have a responsibility to confer information about the benefits and risks of all options.
For questions on CAPPA’s position, please email the Executive Director of Lactation at cledirector@cappa.net.
For more on this topic, I offer lectures. Click here for more information about the Milk Sharing Conundrum speaking engagement.
References:
1.) The Academy of Breastfeeding Medicine Protocol. 2009. ABM Clinical Protocol #3: Hospital Guidelines for the Use of Supplementary Feedings in the Healthy Term Breastfed Neonate. Breastfeeding Medicine 4:3, 175-182.
2.) Block, Jennifer. Move Over, Milk Banks: Facebook and Milk Sharing. Web article. November 22, 2010.
http://www.time.com/time/health/article/0,8599,2032363,00.html#ixzz2DMRUcApk
3.) Human Milk Banking Association Website. https://www.hmbana.org/
4.) Miracle, Donna et al. Contemporary Ethical Issues in Human Milk-Banking in the United States. Pediatrics 128:6, 1186-1191. http://pediatrics.aappublications.org/content/128/6/1186.full
5.) World Health Organization, UNICEF. Global Strategy for infant and young child feeding. WHO Library. Nutrition. 2003. http://www.who.int/nutrition/publications/infantfeeding/9241562218/en/index.html
6.) Walker, S and Armstrong, M. The four pillars of safe breast milk sharing. Midwifery Today International Midwife. 2012 Spring;(101):34-7. http://www.ncbi.nlm.nih.gov/pubmed/22486021?dopt=Abstract or www.eatsonfeets.org/docs/TheFourPillars.pdf
7.) Walker, Shell. Profiting off of Breastmilk. Eats on Feets Blog. November 13, 2011. http://www.eatsonfeets.org/
8.) Finney, Karen et al. Feasibility of Using Flash-Heated Breastmilk as an Infant Feeding Option for HIV-Exposed, Uninfected Infants after 6 Months of Age in Urban Tanzania. UC Davis Researchers, funded by NIH. To request study: karen.finney@ucdmc.ucdavis.edu
Blogs on Milk Sharing
• Supporting Families in milk Sharing as an IBCLC - Amber McCann
• Biomedical Ethics and Peer to Peer Milk Sharing - Dr. Karen Gribble
• Milk-Sharing: Safe Infant Feeding and Being a Human - Sustainable Mothering - Jake Markus
• The Lorax and Other Milksharing stories - MatriciativismoenelsigloXXI Jesusa Ricoy-Olariaga
• Winning the milk lottery - PhD in Parenting, Diana West, BA, IBCLC
• Scared Milk-less - Peaceful Parenting - Lisa Van den Hoven
• Overcoming Difference Through Milksharing - Milk Junkies, Trevor MacDonald
• Biomedical Ethics and Peer-to-Peer Milksharing - Human Milk News, Karleen Gribble
• A Story of Peace and Healing - Normal, like breathing, Diana Cassar-Uhl
• Milksharing and La Leche League - Feed the Baby LLC, Laura Spitzfaden
• Supporting Families in Milksharing as an International Board Certified Lactation Consultant - Nourish Breastfeeding Support, Amber Rhotan McCann
• "I wish I'd Known About Milksharing When..." - Complete Wellness Concept, Dinnae Galloway
• Waiting for Milk Banks: A Matter of Life or Death - Human Milk News, Jodine Chase
• Powerful Images: Supplementing with Donor Milk - DoubleThink, Paa.la, Paala Anderson Secor
• What is World Milksharing Week - Dinnae Galloway